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Knee

    

TOPICS 
ACL Laxity
Baker's Cyst 
Jumper's Knee (See  Patellar Tendinosis) 
Medial Meniscus  Tear
Osteoarthritis Of Knee 
 
ACL LAXITY DEX: Reeves et al 2003 
Dextrose tightens loose ACL ligament by simple Reeves KD Hassanein K Long term effects of dextrose prolotherapy for anterior cruciate ligament laxity: A prospective and consecutive patient study. Alt Ther Hlth Med  May-Jun 2003, 9(3): p58-62.
To read the entire study click here --> View ACL Laxity Study

Method:  16 knees with machine measured ACL laxity (KT-1000 arthrometer) were injected bimonthly with 10-25% dextrose solution for 1 year and then an average of 4 times yearly thereafter until 3 year follow-up.  

Summary:   Using simple dextrose injection into 16 knees with a loose ACL ligament, 10/16 knees were no longer loose by machine measurement at time of follow-up, and symptoms  were improved. Symptom of osteoarthritits improved even in those who still tested loose.   At the 3 year follow-up  pain with walking had improved by 43% ,  subjective swelling improved 63%,  flexion range of motion improved by 10.5 degrees,  and KT1000 ADD (machine measure of ACL ligament looseness) improved by 71%. 

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Here is the abstract:

Reeves KD; Hassanein KM Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity. Altern Ther Health Med (United States), May-Jun 2003, 9(3) p58-62  Prolotherapy is defined as injection that causes growth of normal cells or tissue. OBJECTIVE: Determine the 1 and 3 year efficacy of dextrose injection prolotherapy on anterior cruciate ligament (ACL) laxity. After year 1, determine patient tolerance of a stronger dextrose concentration (25% versus 10%). DESIGN: Prospective consecutive patient trial. SETTING: Outpatient physical medicine clinic. PATIENTS OR OTHER PARTICIPANTS: Eighteen patients with 6 months or more of knee pain plus ACL knee laxity. This laxity was defined by a KT1000 anterior displacement difference (ADD) of 2 mm or more. INTERVENTION: Intraarticular injection of 6-9 cc of 10% dextrose at months 0, 2, 4, 6, and 10. Injection with 6 cc of 25% dextrose at 12 months. Then, depending on patient preference, injection of either 10% or 25% dextrose every 2-4 months (based on patient preference) through 36 months. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) for pain at rest, pain on level surfaces, pain on stairs, and swelling. Goniometric flexion range of motion, and KT1000-measured ADD were also measured. All measurements were obtained at 0, 6, 12 and 36 months. RESULTS: Two patients did not reach 6 month data collection, 1 of whom was diagnosed with disseminated cancer. The second was wheelchair-bound and found long-distance travel to the clinic problematic. Sixteen subjects were available for data analysis. KT1000 ADD, measurement indicated that 6 knees measured as normal (not loose) after 6 months, 9 measured as normal after 1 year (6 Intelligent Design Evidenceinjections), and 10 measured as normal at 3 years. At the 3 year follow-up, pain at rest, pain with walking, and pain with stair use had improved by 45%, 43%, and 35% respectively. Individual paired t tests indicated subjective swelling improved 63% (P = .017), flexion range of motion improved by 10.5 degrees (P = .002), and KT1000 ADD improved by 71% (P = .002). Eleven out of 16 patients preferred 10% dextrose injection. CONCLUSION: In patients with symptomatic anterior cruciate ligament laxity, intermittent dextrose injection resulted in clinically and statistically significant improvement in ACL laxity, pain, swelling, and knee range of motion.

Bakers Cyst: Dextrose + Sodium Morrhuate:  Centeno 2008:  Injection to Shrink a Baker's Cyst WIth X-Ray Confirmation      
Centeno et al demonstrated a case of MRI use to demonstrate shrinking of a Baker's cyst by simply injecting the knee, since the knee lining is connected with the Baker's cyst.  This suggests a favorable change in the joint to stop overproduction of joint fluid which allows the cyst to shrink since it is connected with the knee joint. Simple intra articular injection of 12.5% dextrose and sodium morrhuate on 3 occasions in a patient who failed conservative care and drainage was described.   In the present and near future both MRI and ultrasound scans can be used to objectively document in this way.  Anticipate more such studies.     Centeno CJ; Schultz J; Freeman M. Sclerotherapy of Baker's cyst with imaging confirmation of resolution. Pain Physician (United States), Mar-Apr 2008, 11(2) p257-61 ABSTRACT 

BACKGROUND: Baker's cysts are commonly encountered in pain management practices. OBJECTIVE: To ascertain if sclerotherapy treatment of a Baker's cyst could produce objectively verifiable MRI imaging changes. DESIGN: Case report. METHODS: A 52-year-old white male with a posterior horn of the medial meniscus tear and a large Baker's cyst who had failed conservative care and drainage was imaged before treatment with sclerosing. Three injections of 12.5% dextrose and anesthetic with sodium morrhuate were injected intraarticular into the right knee after drainage. RESULTS: The Baker's cyst resolved on both postoperative imaging after the completion of care as well as on physical examination. CONCLUSIONS: Prolotherapy in this case study seemed to be an effective treatment for Baker's cyst in this patient.  AUTHOR'S ADDRESS: The Centeno-Schultz Clinic Westminster, CO, USA. centenooffice@centenoclinic.com.
 
MEDIAL MENISCUS TEAR Fullerton BD  2007 Healing of a medial meniscus tear. 
The medial meniscus of the knee is  non linear structure. Dr. Fullerton published examples of regeneration from dextrose injection, including an example of repair of a tear in the medial meniscus..   Image B was actually taken after one injection and Image D after 3 injections, with the obvious tear closing in favor of meniscus tissue with normal appearance. The patient stopped having symptoms, the McMurray test became negative and the meniscus also healed according to pre and post MRI scans.    Fullerton BD. High-Resolution Ultrasound and Magnetic Resonance Imaging to Document Tissue Repair After Prolotherapy Arch PM&R 2008. 89(2):377-385

ABSTRACT: High-resolution ultrasound imaging of musculoskeletal tissue is increasing in popularity because of patient tolerability, low cost, ability to visualize tissue in real-time motion, and superior resolution of highly organized tissue such as a tendon. Prolotherapy, defined as the injection of growth factors or growth factor production stimulants to grow normal cells or tissue, has been a controversial procedure for decades; it is currently gaining in popularity among physiatrists and other musculoskeletal physicians. This report describes imaging of tendons, ligaments, and medial meniscus disease (from trauma or degeneration). Although these tissues have been poorly responsive to nonsurgical treatment, it is proposed that tissue growth and repair after prolotherapy in these structures can be documented with ultrasound and confirmed with magnetic resonance imaging. Directions for future research application are discussed. 

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Osteoarthritis:  Stem Cell Use:  Case Report Centeno 2008  
Centeno CJ, Busse D, Kisiday J, Keohan C, Freeman M, Karli D. Increased knee cartilage volume in degenerative joint disease using percutaneously implanted, autologous mesenchymal stem cells. Pain Physician (United States), May-Jun 2008, 11(3) p343-53
200 ml of blood was drawn from a sngle patient  and spun down to provide platelet rich plasma to support the bone marrow cultures.  --> 10 ml of L post sup iliac spine (PSIS) marrow was obtained and 10 ml of R PSIS marrow in an operating room.  --> 5 passages (culture method with 5 periods of growth to allow enough stem cells to be obtained) were taken to separate and concentrate the MSCs (mesenchymal stem cells or cells that can become ligament, tendon and cartilage cells).   -->  Bone marrow aspiration is performed again to obtain 1 ml of fresh nucleated cells, and blood is drawn for a fresh platelet rich plasma component with the latter diluted to 10% platelet solution.  --> The cultured and grown MSCs are injected along with the 1 ml of nucleated cells and 1 ml of platelets into the knee .   --> 1 ml of dilute (10%) platelets were then injected  in the knee one week after stem cell injection-->   1 ml of dilute (10%) platelets were then injected  in the knee two weeks after stem cell injection 

Therefore, in summary the interventions taken included 3 bone marrow aspirations, 4 blood draws for platelet rich plasma, and 3 knee injections. In addition there was a time lag for culture prep and passages of MSCs. This is a lot of interventions and expense of course.    Nevertheless this is an excellent study in that it explains the process with the best of current technology and this was a 6 month followup.   Notice that the patient in this study appeared to have some cartilage left.   Here is that abstract and the PDF is available on line for a fee from the company. 
ABSTRACT:

BACKGROUND: The ability to repair tissue via percutaneous means may allow interventional pain physicians to manage a wide variety of diseases including peripheral joint injuries and osteoarthritis. This review will highlight the developments in cellular medicine that may soon permit interventional pain management physicians to treat a much wider variety of clinical conditions and highlight an interventional case study using these technologies OBJECTIVE: To determine if isolated and expanded human autologous mesenchymal stem cells could effectively regenerate cartilage and meniscal tissue when percutaneously injected into knees. DESIGN: Case Study SETTING: Private Interventional Pain Management practice. METHODS: An IRB approved study with a consenting volunteer in which mesenchymal stem cells were isolated and cultured ex-vivo from bone marrow aspiration of the iliac crest. The mesenchymal stem cells were then percutaneously injected into the subject's knee with MRI proven degenerative joint disease. Pre- and post-treatment subjective visual analog pain scores, physical therapy assessments, and MRIs measured clinical and radiographic changes. RESULTS: At 24 weeks post-injection, the patient had statistically significant cartilage and meniscus growth on MRI, as well as increased range of motion and decreased modified VAS pain scores. CONCLUSION: The described process of autologous mesenchymal stem cell culture and percutaneous injection into a knee with symptomatic and radiographic degenerative joint disease resulted in significant cartilage growth, decreased pain and increased joint mobility in this patient. This has significant future implications for minimally invasive treatment of osteoarthritis and meniscal injury.
 
Osteoarthritis of Knee DEX Reeves et al 2000  
10% dextrose versus hypotonic lidocaine in advanced Knee OA   In this study of patients with advanced knee osteoarthritis (bone on bone on skier's view in 35/111 knees) the 10%  dextrose injection was superior to the hypotonic lidocaine solution injection, (p =0.15) showing better results in walking pain (35%), subjective swelling(45%), a 67% reduction in knee buckling episodes, and a substantial (13 degree) improvement in active knee bending ability.  It is important to note that the control solution (0.1% lidocaine)  was not likely a placebo because injection resulted in 26% improvement in walking pain and a 7.7 degree increase in goniometrically measured knee range of motion.  Hypotonic solutions have effects on growth factors too, and tonicity of control solutions should be considered in study designs. 

Reeves KD Hassanein K Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alt Ther Hlth Med 2000;6(2):37-46. To open a PDF of the study click here ->View Knee Study

Subjects had chronic knee pain (6 months minimum with an average of 8 years). The average cartilage thickness was only 3 mm on skier's view (medial compartment primarily)   The treatment consisted of 3 injections of 9 cc of 10% dextrose solution over 6 months versus an identical volume hypotonic lidocaine solution.

Note the "control" solution, chosen for maximum safety in human subject committee submission was bacteriostatic water with low dose (0.1%) lidocaine).  This calculated osmolarity is 105 mOsm, and less than 250 mOsm we now know affects growth factors and may not be a placebo.    

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Here is the abstract
Reeves KD Hassanein K Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alt Ther Hlth Med 2000;6(2):37-46. Context: Prolotherapy in arthritis Objective: Determine the effects of injection of hypertonic dextrose on knee osteoarthritis.  Design: Prospective randomized double-blind controlled trial. Setting: Outpatient physical medicine clinic. Patients or other participants: 6 months or more of pain and either grade 2 or 3 joint narrowing or grade 2 or 3 osteophyte in any knee compartment. Intervention: Three bimonthly injections of 9 c.c. of either 10% Dextrose and .075% Xylocaine in bacteriostatic water (active solution) versus an identical control solution absent 10% Dextrose. The dextrose-treated joints then received 3 further bimonthly injections of 10% dextrose in open-label fashion. Main Outcome Measures: 100 mm visual analogue scale (V.A.S.) for rest pain, walking pain, standing pain, and swelling. The number of buckling episodes were estimated over the preceding two months. Flexion was goniometrically measured in blinded fashion. Radiographic measures of cartilage thickness, osteophyte grade, and hypertrophic change were obtained. Results: The magnitude of improvement in subjective and objective measures in control-treated knees suggested that the control solution (water) may have had more than a placebo effect. Nevertheless, Hotelling multivariate analysis of paired observations between 0 and 6 months for pain, swelling, buckling episodes, and flexion revealed significantly more benefit from the dextrose injection, (p = .015 ) . By 12 months (6 injections) the dextrose-treated knees improved in pain, swelling, knee buckling and flexion by 44%, 63%, 85% and 14 degrees respectively. Analysis of blinded radiographic readings of 0 and 12 month films revealed a statistically significant improvement in radiographic measures of osteoarthritis from 0 to 12 months.  Conclusion: Prolotherapy (Injection to produce a growth or repair response in body cells) utilizing sub-inflammatory levels of dextrose (10%) solution, when performed bimonthly, resulted in clinically and statistically significant improvements in knee osteoarthritis. Blinded radiographic follow up at 1 year suggests improvement in several measures of osteoarthritic severity.  Key words: Osteoarthritis, knee, growth substances, proliferative, hypertonic, hypotonic.   
 
Patellar Tendinosis: (Jumper's Knee)  POLIDOCANOL: Alfredson et al 2005  
15 elite or recreational athletes with patellar tendinosis/jumpers knee were injected with Polidocanol, targeting areas of neovascularization. At 6 month followup there was a good clinical result in 12/15 tendons. With previous sport level reached in 12/15 and pain decrease (VAS) from 81 to 10 on a 100 point scale. Alfredson H; Ohberg L Neovascularisation in chronic painful patellar tendinosis--promising results after sclerosing neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc (Germany), Mar 2005, 13(2) p74-80

ABSTRACT: Sclerosing injections targeting neovascularisation have been demonstrated to give promising clinical results in patients with chronic painful Achilles tendinosis. In this study, fifteen elite or recreational athletes (12 men and three women) with the diagnosis patellar tendinosis/Jumper's knee in 15 patellar tendons were included. All the patients had a long duration of pain symptoms (mean = 23 months) from the patellar tendon, and ultra-sonography + colour doppler examination showed structural tendon changes with hypo-echoic areas and a neovascularisation, corresponding to the painful area. The patients were treated with ultrasound and colour doppler-guided injections of the sclerosing substance Polidocanol, targeting the area with neovascularisation. At follow-up (mean = 6 months) after a mean amount of three treatments, there was a good clinical result in 12/15 tendons. The patients were back to their previous (before injury) sport activity level, and the amount of pain recorded on a VAS-scale had decreased significantly (VAS from 81 to 10). Our findings indicate that treatment with sclerosing injections, targeting the area with neovessels in patellar tendinosis, has the potential to cure the pain in the tendons and also allow the patients to go back to full patellar-tendon loading activity.

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